Overcoming Therapeutic Inertia in Multiple Sclerosis Care: A Pilot Randomized Trial Applying the Traffic Light System in Medical Education

Abstract

BackgroundPhysicians often do not initiate or intensify treatments when clearly warranted, a phenomenon known as therapeutic inertia (TI). Limited information is available on educational interventions to ameliorate knowledge-to-action gaps in TI.ObjectivesTo evaluate the feasibility and efficacy of an educational intervention compared to usual care among practicing neurologists caring for patients with multiple sclerosis (MS).MethodsWe conducted a pilot double-blind, parallel-group, randomized clinical trial. Inclusion criteria included neurologists who are actively involved in managing MS patients. Participants were exposed to 20 simulated case-scenarios (10 cases at baseline, and 10 cases post-randomization to usual care vs. educational intervention) of relapsing–remitting MS with moderate or high risk of disease progression. The educational intervention employed a traffic light system (TLS) to facilitate decisions, allowing participants to easily recognize high-risk scenarios requiring treatment escalation. We also measured differences between blocks to invoke decision fatigue. The control group responded as they would do in their usual clinical practice not exposed to the educational intervention. The primary feasibility outcome was the proportion of participants who completed the study and the proportion of participants who correctly identified a high-risk case-scenario with the “red traffic light.” Secondary outcomes included decision fatigue (defined as an increment of TI in the second block of case-scenarios compared to the first block) and the efficacy of the educational intervention measured as a reduction in TI for MS treatment.ResultsOf 30 neurologists invited to be part of the study, the participation rate was 83.3% (n = 25). Of the 25 participants, 14 were randomly assigned to the control group and 11 to the intervention group. TI was present in 72.0% of participants in at least one case scenario. For the primary feasibility outcome, the completion rate of the study was 100% (25/25 participants). Overall, 77.4% of participants correctly identified the “red traffic light” for clinical-scenarios with high risk of disease progression. Similarly, 86.4% of participants correctly identified the “yellow traffic light” for cases that would require a reassessment within 6–12 months. For the secondary fatigue outcome, within-group analysis showed a significant increased prevalence of TI in the second block of case-scenarios (decision fatigue) among participants randomized to the control group (TI pre-intervention 57.1% vs. TI post-intervention 71.4%; p = 0.015), but not in the active group (TI pre-intervention 54.6% vs. TI post-intervention 63.6%; p = 0.14). For the efficacy outcome, we found a non-significant reduction in TI for the targeted intervention compared to controls (22.6 vs. 33.9% post-intervention; OR 0.57; 95% CI 0.26–1.22).ConclusionAn educational intervention applying the TLS is feasible and shows some promising results in the identification of high-risk scenarios to reduce decision fatigue and...

Therapeutic Inertia in Multiple Sclerosis Care: A Study of Canadian Neurologists

“…Of interest is the comparison of TI in neurologists from Canada vs. that of neurologists from other countries (Argentina, Chile, and Spain) ( 22 ). Our analysis revealed that Canadian participants had a significantly lower TI.…”

“…Values lower than 10 healthy-years of survival would represent aversion to the risks of treatment, whereas higher values would represent risk-prone individuals. A study with a similar protocol and design was conducted in Argentina and Chile in 2017 ( 22 ). Details of the protocol were published in previous publications ( 17 , 20 ).…”

“…For the present analysis, we used the aforementioned scheme according to the current clinical practice ( 3 , 18 ). Data from historical controls were obtained from previous/in press publications ( 22 ).…”

Applying Behavioral Economics and Neuroeconomics to Medical Education and Clinical Care

“…The application of the TLS was feasible and promising by showing a trend towards a reduction in TI compared to controls (OR 0.57; 95% CI 0.26-1.22). 8 In another study, the authors assessed herding among 96 neurologists with expertise in MS. Herding is a phenomenon that can occur in MS when neurologists follow a therapeutic recommendation by a colleague even though it is not supported by best practice clinical guidelines. Nearly 8 out of 10 neurologists exhibited herding.…”

Therapeutic Inertia in the New Landscape of Multiple Sclerosis Care

“…For example, classic studies in consumer research showed that the higher the number of available options may negatively influence consumer’s decisions due to information overload ( 10 ). Moreover, the time of the day influences assertive decisions, phenomenon called “decision fatigue.” Similarly, 7 out of 10 neurologists expressed TI as a result of these factors and lower tolerance to uncertainty ( 11 ). This is not surprising given that neurology practice is a medical specialty with higher incidence of physicians’ biases and burnout, and MS being a neurological condition leading the paradigm of multiple therapeutic choices with ongoing developments—altogether the perfect combination for TI ( , accessed December 15, 2017).…”